GnRH antagonist-induced inhibition of the premature LH surge increases pregnancy rates in IUI-stimulated cycles. A prospective randomized trial

Cumulative live birth rate of in vitro fertilization cycle via progestin-primed ovarian stimulation versus gonadotropin-releasing hormone antagonist protocol in infertile women with normal ovarian reserve: an open-label, randomized controlled trial

This study aimed to evaluate the cumulative live birth rate (cLBR) of progestin-primed ovarian stimulation (PPOS) protocol versus gonadotropin-releasing hormone antagonist (GnRH-ant) protocol for in vitro fertilization (IVF) cycle in infertile women with normal ovarian reserve (NOR). Infertile women with NOR who underwent their first IVF cycle were enrolled in an open-label randomized controlled trial. Patients were randomly assigned 1:1 to receive a freeze-all strategy with delayed embryo transfer (PPOS group, n = 174) and fresh embryo transfer first (GnRH-ant group, n = 174). The primary outcome was the cLBR per aspiration. The cLBR between the PPOS group and GnRH-ant group were comparable (55.75% vs. 52.87%, p = 0.591). A premature luteinizing hormone surge was not observed in the PPOS group, while there were six cases (3.45%) in the GnRH-ant group, but no premature ovulation in either of the groups. The pregnancy outcomes, including implantation rate, clinical pregnancy rate and miscarriage rate, were all comparable. In addition, the number of retrieved oocytes, mature oocytes and viable embryos were similar (all p > 0.05) between the two groups.

GnRH antagonist protocol versus progestin-primed ovarian stimulation in patients with polycystic ovary syndrome: a systematic review and meta-analysis

PURPOSE

The aim of this meta-analysis was comparing the efficacy of GnRH antagonist (GnRH-ant) protocol and progestin-primed ovarian stimulation (PPOS) in polycystic ovarian syndrome (PCOS) women.

METHODS

A search was conducted from PubMed, Embase, The Cochrane library, Web of Science, and Scopus databases to collect clinical papers regarding GnRH-ant protocol and PPOS protocol from inception to September 2023. Subsequently, the retrieved documents were screened, and the content of the documents that conformed to the requirements was extracted. Moreover, statistical meta-analyses were conducted using the RevMan 5.4 software. Furthermore, with the use of a star-based system and the Cochrane handbook, the methodological quality of the covered papers was evaluated on the Ottawa-Newcastle scale.

RESULTS

A total of eight papers were covered in the meta-analysis, with 2156 PCOS women enrolled (i.e., 1085 patients in the GnRH-ant protocol group and 1071 patients in the PPOS group). As indicated by the meta-analysis results, the PPOS group was correlated with a lower risk of ovarian hyperstimulation syndrome (OHSS) (SMD = 9.24, [95% CI: (2.50, 34.21)], P = 0.0009), more gonadotropin (Gn) dose (SMD = - 0.34, [95% CI: (- 0.56, - 0.13)], P = 0.002) compared with GnRH-ant group. No statistical difference was identified on the oocytes condition and pregnancy outcomes.

CONCLUSIONS

As revealed by the data of this study, the progesterone protocol is comparable with the GnRH-ant protocol in oocytes condition and clinical outcomes. The progestin-primed ovarian stimulation could serve as an alternative for polycystic ovarian syndrome women who have failed in GnRH antagonist protocol. The above-described conclusions should be verified by more high-quality papers due to the limitation of the number and quality of included papers.

TRIAL REGISTRATION

PROSPERO registration: CRD42023411284.

Young obese patients may benefit from GnRH-a long protocol contributing to higher implantation rate and live birth rate of fresh IVF-ET cycles

Introduction

Obesity has detrimental influences on women reproductive health. There is little experience in optimizing controlled ovarian hyperstimulation (COH) protocols to treat Chinese obese patients who are undergoing in vitro fertilization and embryo transfer (IVF-ET) therapy.

Methods

The clinical outcome differences were retrospectively analyzed among obese patients who received gonadotrophin-releasing hormone agonist (GnRH-a), GnRH antagonist (GnRH-ant), micro dose GnRH-a (mGnRH-a) and GnRH-a long protocol in IVF-ET cycle at Chengdu Jinjiang Hospital for Women's and Children's Health from January 2014 to December 2019.

Results

The transplantation rate of the GnRH-a long protocol group (59.1%) was higher than that of the GnRH-ant (25.9%) and mGnRH-a (36.7%) groups. The total live birth rate of the GnRH-a long protocol group (46.2%) was higher than that of the GnRH-a group (25.9%) and GnRH-ant group (40.3%). The total number of frozen embryos in the GnRH-ant group was higher than in the other groups (P < 0.05). After adjusting for confounding factors, the logistic regression analysis showed that the GnRH-a long protocol group had higher probabilities of biochemical pregnancy, clinical pregnancy, and live birth than the GnRH-a protocol group. The Gn dose in the mGnRH-a group was higher than the other three groups. Whether single or twin, there were similar neonatal outcomes among the four groups including premature birth rate, Apgar score, newborn weight, and length.

Conclusion

For young obese patients undergoing IVF-ET, the GnRH-a long protocol for COH gives better pregnancy outcomes.

Does elevated luteinizing hormone level before trigger mean premature luteinizing hormone surge in advanced-aged women undergoing mild ovarian stimulation?

OBJECTIVE

To explore whether elevated luteinizing hormone (LH) level before trigger means premature LH surge in advanced aged women undergoing mild ovarian stimulation.

METHODS

To retrospectively analyze 235 in vitro fertilization/intracytoplasmic sperm injection cycles in women >35 years old with the poor ovarian response (POR) from January 2012 to March 2016. Cycles are named Group 1, Group 2, and Group 3, being treated with gonadotropin-releasing hormone antagonist protocol (76 cycles), mild stimulation protocol using clomiphene citrate (73 cycles), and tamoxifen (86 cycles), respectively.

MAIN OUTCOME MEASURE(S)

The dynamic change of LH level during stimulation; the proportion of an elevated LH level defined as >10 IU/L on trigger day; the proportion of premature ovulation in each group.

RESULTS

Serum LH level increased early in Group 2 and Group 3 and remained significantly higher than that in Group 1 during stimulation. In a sequence of three groups, the proportion of elevated LH levels before the trigger was 11.84, 43.8, and 37.21% (p＜.001) respectively. And the proportion of premature ovulation in patients with elevated LH levels was 11.11, 18.75, and 25% (p = .11) respectively.

CONCLUSION

Elevated LH level before trigger does not mean premature LH surge in women more than 35 years old with POR undergoing mild ovarian stimulation with clomiphene or tamoxifen.

Agents for ovarian stimulation for intrauterine insemination (IUI) in ovulatory women with infertility

BACKGROUND

Intrauterine insemination (IUI), combined with ovarian stimulation (OS), has been demonstrated to be an effective treatment for infertile couples. Several agents for ovarian stimulation, combined with IUI, have been proposed, but it is still not clear which agents for stimulation are the most effective. This is an update of the review, first published in 2007.

OBJECTIVES

To assess the effects of agents for ovarian stimulation for intrauterine insemination in infertile ovulatory women.

SEARCH METHODS

We searched the Cochrane Gynaecology and Fertility Group trials register, CENTRAL, MEDLINE, Embase, PsycINFO, CINAHL and two trial registers from their inception to November 2020. We performed reference checking and contacted study authors and experts in the field to identify additional studies.

SELECTION CRITERIA

We included truly randomised controlled trials (RCTs) that compared different agents for ovarian stimulation combined with IUI for infertile ovulatory women concerning couples with unexplained infertility. mild male factor infertility and minimal to mild endometriosis.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures recommended by Cochrane.

MAIN RESULTS

In this updated review, we have included a total of 82 studies, involving 12,614 women. Due to the multitude of comparisons between different agents for ovarian stimulation, we highlight the seven most often reported here. Gonadotropins versus anti-oestrogens (13 studies) For live birth, the results of five studies were pooled and showed a probable improvement in the cumulative live birth rate for gonadotropins compared to anti-oestrogens (odds ratio (OR) 1.37, 95% confidence interval (CI) 1.05 to 1.79; I² = 30%; 5 studies, 1924 participants; moderate-certainty evidence). This suggests that if the chance of live birth following anti-oestrogens is assumed to be 22.8%, the chance following gonadotropins would be between 23.7% and 34.6%. The pooled effect of seven studies revealed that we are uncertain whether gonadotropins lead to a higher multiple pregnancy rate compared with anti-oestrogens (OR 1.58, 95% CI 0.60 to 4.17; I² = 58%; 7 studies, 2139 participants; low-certainty evidence). Aromatase inhibitors versus anti-oestrogens (8 studies) One study reported live birth rates for this comparison. We are uncertain whether aromatase inhibitors improve live birth rate compared with anti-oestrogens (OR 0.75, CI 95% 0.51 to 1.11; 1 study, 599 participants; low-certainty evidence). This suggests that if the chance of live birth following anti-oestrogens is 23.4%, the chance following aromatase inhibitors would be between 13.5% and 25.3%. The results of pooling four studies revealed that we are uncertain whether aromatase inhibitors compared with anti-oestrogens lead to a higher multiple pregnancy rate (OR 1.28, CI 95% 0.61 to 2.68; I² = 0%; 4 studies, 1000 participants; low-certainty evidence).  Gonadotropins with GnRH (gonadotropin-releasing hormone) agonist versus gonadotropins alone (4 studies) No data were available for live birth. The pooled effect of two studies  revealed that we are uncertain whether gonadotropins with GnRH agonist lead to a higher multiple pregnancy rate compared to gonadotropins alone (OR 2.53, 95% CI 0.82 to 7.86; I² = 0; 2 studies, 264 participants; very low-certainty evidence).  Gonadotropins with GnRH antagonist versus gonadotropins alone (14 studies) Three studies reported live birth rate per couple, and we are uncertain whether gonadotropins with GnRH antagonist improve live birth rate compared to gonadotropins (OR 1.5, 95% CI 0.52 to 4.39; I² = 81%; 3 studies, 419 participants; very low-certainty evidence). This suggests that if the chance of a live birth following gonadotropins alone is 25.7%, the chance following gonadotropins combined with GnRH antagonist would be between 15.2% and 60.3%. We are also uncertain whether gonadotropins combined with GnRH antagonist lead to a higher multiple pregnancy rate compared with gonadotropins alone (OR 1.30, 95% CI 0.74 to 2.28; I² = 0%; 10 studies, 2095 participants; moderate-certainty evidence). Gonadotropins with anti-oestrogens versus gonadotropins alone (2 studies) Neither of the studies reported data for live birth rate. We are uncertain whether gonadotropins combined with anti-oestrogens lead to a higher multiple pregnancy rate compared with gonadotropins alone, based on one study (OR 3.03, 95% CI 0.12 to 75.1; 1 study, 230 participants; low-certainty evidence). Aromatase inhibitors versus gonadotropins (6 studies) Two studies  revealed that aromatase inhibitors may decrease live birth rate compared with gonadotropins (OR 0.49, 95% CI 0.34 to 0.71; I²=0%; 2 studies, 651 participants; low-certainty evidence). This suggests that if the chance of a live birth following gonadotropins alone is 31.9%,  the chance of live birth following aromatase inhibitors would be between 13.7% and 25%. We are uncertain whether aromatase inhibitors compared with gonadotropins lead to a higher multiple pregnancy rate (OR 0.69, 95% CI 0.06 to 8.17; I²=77%; 3 studies, 731 participants; very low-certainty evidence).  Aromatase inhibitors with gonadotropins versus anti-oestrogens with gonadotropins (8 studies) We are uncertain whether aromatase inhibitors combined with gonadotropins improve live birth rate compared with anti-oestrogens plus gonadotropins (OR 0.99, 95% CI 0.3 8 to 2.54;  I² = 69%; 3 studies, 708 participants; very low-certainty evidence). This suggests that if the chance of a live birth following anti-oestrogens plus gonadotropins is 13.8%, the chance following aromatase inhibitors plus gonadotropins would be between 5.7% and 28.9%. We are uncertain of the effect of aromatase inhibitors combined with gonadotropins compared to anti-oestrogens combined with gonadotropins on multiple pregnancy rate (OR 1.31, 95% CI 0.39 to 4.37;  I² = 0%; 5 studies, 901 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

Based on the available results, gonadotropins probably improve cumulative live birth rate compared with anti-oestrogens (moderate-certainty evidence). Gonadotropins may also improve cumulative live birth rate when compared with aromatase inhibitors (low-certainty evidence). From the available data, there is no convincing evidence that aromatase inhibitors lead to higher live birth rates compared to anti-oestrogens. None of the agents compared lead to significantly higher multiple pregnancy rates. Based on low-certainty evidence, there does not seem to be a role for different combined therapies, nor for adding GnRH agonists or GnRH antagonists in IUI programs.

Comparison of GnRH-a Prolonged Protocol and Short GnRH-a Long Protocol in Patients with Thin Endometrium for Assisted Reproduction: A Retrospective Cohort Study

Purpose

Gonadotrophin releasing hormone agonist (GnRH-a) is widely used for pituitary down-regulation and recruiting more follicles in assisted reproduction. However, no information is available on its value for patients with thin endometrial thickness.

Patients and Methods

This was a retrospective cohort study of 302 patients with endometrium <8 mm undergoing fresh embryo transfer at a fertility center of a university hospital from January 2016 and December 2018. In 148 cycles of the GnRH-a prolonged protocol, one depot of 3.75 mg GnRH-a was injected on day 2 of the menstrual cycle, while in 154 cycles of the short GnRH-a long protocol, 0.1 mg of GnRH-a was injected daily from the mid-luteal phase. The live birth rate and clinical pregnancy rate were compared between the two groups. Other outcome measures included the implantation rate, miscarriage rate, and characteristics of stimulation procedures.

Results

Live birth rates and clinical pregnancy rates were significantly higher in the GnRH-a prolonged protocol group than in the other group (36.5% vs 20.8%, P=0.002; 43.9% vs 28.2%, P=0.006, respectively). The live birth rate was significantly increased in the prolonged protocol group (crude OR: 2.190, 95% CI: 1.311, 3.660; adjusted OR: 2.458, 95% CI: 1.430, 4.224) compared with that in the reference group. The implantation rate of the former group was also significantly higher than that of the latter group (35.4% vs 15.9%, P=0.000). There was no significant difference in miscarriage rates between the two protocols. In terms of stimulation procedures, the GnRH-a prolonged protocol group required significantly higher Gn time (10.9 vs 9.5 days, P=0.000) and Gn consumption (2625.0 vs 2047.5 IU, P=0.000) than the short GnRH-a long protocol group.

Conclusion

The GnRH-a prolonged protocol in fresh embryo transfer cycles yielded better clinical outcomes of patients with thin endometrium than the short GnRH-a long protocol.

Initial ovarian sensitivity index predicts embryo quality and pregnancy potential in the first days of controlled ovarian stimulation

BACKGROUND

To determine if a modified ovarian sensitivity index (MOSI), based on initial follicular measurements and the initial follicle-stimulating hormone (FSH) dose, can predict the production of high-quality embryos for successful implantation during in vitro fertilization (IVF).

METHODS

This study consisted of two phases: 1) a retrospective study and 2) a prospective observational study. For the first phase, 363 patients charts were reviewed, of which 283 had embryos transferred. All women underwent a standardized antagonist-based IVF protocol. At the first follow-up (Day 3/4), the number and size of the follicles were determined. MOSI was calculated as ln (number follicles (≥6 mm) × 1000 / FSH initial dose). Afterward, the number and quality of the ova, embryo development, and the number and quality of the blastocysts were determined. Embryo implantation was confirmed by β-hCG. For the second phase, 337 IVF cycles were followed to determine MOSI's accuracy.

RESULTS

MOSI could predict the production of ≥4 high-quality embryos by Day 2 (AUC = 0.69, 95%CI:0.63-0.75), ≥2 blastocysts (AUC = 0.74, 95%CI:0.68-0.79), and ≥ 35% rate of blastocyst formation (AUC = 0.65, 95%CI:0.58-0.72). Using linear regression, MOSI was highly associated with the number of ova captured (β = 5.15), MII oocytes (β = 4.31), embryos produced (β = 2.90), high-quality embryos (β = 0.98), and the blastocyst formation rate (β = 0.06, p < 0.01). Using logistic regression, MOSI was highly associated with achieving ≥4 high-quality embryos (odds ratio = 2.80, 95%CI:1.90-4.13), ≥2 blastocysts (odds ratio = 3.40, 95%CI:2.33-4.95), and ≥ 35% blastocysts formation rate (odds ratio = 1.96, 95%CI:1.31-2.92). This effect was independent of age, BMI, and antral follicle count. For implantation, MOSI was significantly associated with successful implantation (odds ratio = 1.79, 95%CI:1.25-2.57). For the prospective study, MOSI was highly accurate at predicting ≥6 high-quality embryos on Day 2 (accuracy = 68.5%), ≥6 blastocysts (accuracy = 68.0%), and a blastocyst formation rate of ≥35% (accuracy = 61.4%).

CONCLUSION

MOSI was highly correlated with key IVF parameters that are associated with achieved pregnancy. Using this index with antagonist cycles, clinicians may opt to stop an IVF cycle, under the assumption that the cycle will fail to produce good blastocysts, preventing wasting the patient's resources and time.

The effect of a transient premature luteinizing hormone surge without elevated serum progesterone on in vitro fertilization outcomes in a gonadotropin-releasing hormone antagonist flexible protocol

During controlled ovarian stimulation, the LH rising before triggering can lead to follicular luteinizations. However, LH can be suppressed immediately and no progesterone elevation with GnRH antagonist. This study retrospectively compared fresh IVF/ICSI cycle outcomes in antagonist protocols between the group with and the group without a premature LH surge. Logistic regression models were fitted to reduce the relevant confounders. Compared between premature LH surge group and control group, the implantation rates were 12.9% (30/233) vs 25.0% (141/536), p = .000; clinical pregnancy rates were 21.0% (25/119) vs 41.6% (119/286), p = .000; live birth rates were17.6% (21/119) vs 29.7% (85/286), p = .012. After adjusting for age, BMI, bFSH, and infertility factors, the adverse effects were still as pronounced for the clinical pregnancy rate (OR = 0.39, 95% CI = 0.24-0.66) and live birth rates (OR = 0.54, 95% CI = 0.32-0.93. In a GnRH antagonist flexible protocol, a transient premature LH surge which can be suppressed immediately after the initiation of antagonist without elevated serum progesterone, will cause a detrimental effect on the development of the embryo and IVF/ICSI pregnancy outcomes in fresh embryo transfer cycles.

Gonadotropin releasing hormone antagonist use in controlled ovarian stimulation and intrauterine insemination cycles in women with polycystic ovary syndrome

OBJECTIVE

To evaluate the effect of the GnRH antagonist on gonadotropin ovulation induction in women with PCOS.

MATERIALS AND METHODS

A total of 175 intrauterine insemination (IUI) cycles in women with polycystic ovary syndrome (PCOS) were included in the study. Women in the control group (n = 87) underwent controlled ovarian stimulation (COS) with recombinant follicle stimulating hormone (r-FSH) only, while women in the study group (n = 88) were administered r-FSH plus cetrorelix.

RESULTS

As expected, the mean value of luteinizing hormone and progesterone, on the day of human chorionic gonadotropin administration were statistically significantly lower in patients receiving GnRH antagonist than the control group (p = 0.002). Premature luteinization occurred in only one of the patients in the GnRH antagonist group (1.1%) and in 15 of the 88 cycles in the control group (17.2%), showing a significant difference between the two groups (P = 0.001). The clinical pregnancy rate per cycle was higher in GnRH-antagonist group compared to the control group but the difference did not reach to a statistical significance (25% vs 14.9%, P = 0.096).

CONCLUSIONS

Adding GnRH-antagonist in COS/IUI cycles in women with PCOS resulted in a lower incidence of premature luteinization but did not improve pregnancy rates. However, owing to some benefits, antagonist therapy could be considered as a reasonable alternative to IVF in order to reduce PCOS patients'emotional distress.

Comparison of Two Regimens of Gonadotropin-releasing Hormone Antagonists in Clomiphene-gonadotropin Induced Controlled Ovulation and Intrauterine Insemination Cycles: Randomized Controlled Study

Context:

Gonadotropin-releasing hormone (GnRH) antagonists in fixed or flexible regimens are used for prevention of premature luteinizing hormone (LH) surge, however, data comparing these regimens in stimulated intrauterine insemination (IUI) cycles are lacking.

Aims:

The aim of this study is to evaluate the effectiveness of GnRH antagonists in fixed and flexible regimens on the rate of premature luteinization (PL) and ovulation rate in sequential clomiphene-gonadotropin controlled ovulation–IUI cycles.

Settings and Design:

This study was conducted at tertiary care center; this was randomized controlled study.

Materials and Methods:

A total of 45 infertile women randomized into three groups of 15 each received clomiphene citrate + human menopausal gonadotrophin. GnRH antagonist was added according to fixed (n = 15) and flexible (n = 15) protocol. No antagonist in control group (n = 15). PL was defined as LH level ≥10 mIU/ml and progesterone level ≥1.0 ng/ml.

Statistical Analysis:

Mean values compared using the Student's t-test or one-way analysis of variance. Categorical variables distribution tested using either Pearson's Chi-square or Fisher's exact test as appropriate.

Results:

Of a total of 45 women, 58% (n = 26) presented with primary and 42% (n = 19) secondary infertility with mean age of 30.8 ± 3.43 years and BMI 26.57 ± 3.22 kg/m². Fixed regimen (3.7%) showed most reduction in PL compared to flexible (15.38%, P = 0.33) or control (36.67%, P = 0.004). On human chorionic gonadotropin day, mean LH (P = 0.002) and progesterone (P = 0.079) levels in fixed, flexible, and control groups were as follows: 5.04 ± 5.47 mIU/ml, 3.95 ± 4.16 mIU/ml, 9.57 ± 7.91 mIU/ml, and 0.409 ± 0.320 ng/ml, 0.579 ± 0.727 ng/ml, and 1.033 ± 1.022 ng/ml, respectively. Ovulation (P = 0.813) and pregnancy rates (P = 0.99) were 88.9%, 84.6%, and 90% and 22.2%, 19.23%, and 10% in fixed, flexible, and control groups, respectively.

Conclusions:

Addition of antagonist in any regimen appears to lower PL rates and improve pregnancy rates in controlled ovarian stimulation and IUI cycles.

Pituitary block with gonadotrophin-releasing hormone antagonist during intrauterine insemination cycles: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Several randomised controlled trials (RCTs) have investigated the usefulness of pituitary block with gonadotrophin-releasing hormone (GnRH) antagonists during intrauterine insemination (IUI) cycles, with conflicting results.

OBJECTIVE

The aim of the present systematic review and meta-analysis of RCTs was to evaluate the effectiveness of GnRH antagonist administration as an intervention to improve the success of IUI cycles.

SEARCH STRATEGY

Electronic databases (MEDLINE, Scopus, EMBASE, Sciencedirect) and clinical registers were searched from their inception until October 2017.

SELECTION CRITERIA

Randomised controlled trials of infertile women undergoing one or more IUI stimulated cycles with GnRH antagonists compared with a control group.

DATA COLLECTION AND ANALYSIS

The primary outcomes were ongoing pregnancy/live birth rate (OPR/LBR) and clinical pregnancy rate (CPR). Pooled results were expressed as odds ratio (OR) or mean differences with 95% confidence interval (95% CI). Sources of heterogeneity were investigated through sensitivity and subgroups analysis. The body of evidence was rated using GRADE methodology. Publication bias was assessed with funnel plot, Begg's and Egger's tests.

MAIN RESULTS

Fifteen RCTs were included (3253 IUI cycles, 2345 participants). No differences in OPR/LBR (OR 1.14, 95% CI 0.82-1.57, P = 0.44) and CPR (OR 1.28, 95% CI 0.97-1.69, P = 0.08) were found. Sensitivity and subgroup analyses did not provide statistical changes in pooled results. The body of evidence was rated as low (GRADE 2/4). No publication bias was detected.

CONCLUSION

Pituitary block with GnRH antagonists does not improve OPR/LBR and CPR in women undergoing IUI cycles.

TWEETABLE ABSTRACT

Pituitary block with GnRH antagonists does not improve the success of IUI cycles.

Luteal Phase Ovarian Stimulation May Improve Oocyte Retrieval and Oocyte Quality in Poor Ovarian Responders Undergoing In Vitro Fertilization: Preliminary Results from a Single-Center Prospective Pilot Study

INTRODUCTION

Luteal phase ovarian stimulation (LPOS) has been proven a feasible protocol for infertile patients. High progesterone level in the luteal phase could physiologically inhibit premature luteinizing hormone surge, from which poor ovarian responders (PORs) could obtain benefits. Therefore, we aimed to compare clinical outcomes between LPOS and follicular phase ovarian stimulation (FPOS) protocol in PORs undergoing in vitro fertilization (IVF).

METHODS

This prospective pilot study was performed at one tertiary center from January 2016 to October 2017. A total of 60 PORs who met Bologna criteria and undergoing IVF were enrolled. Thirty PORs were allocated to the LPOS group and 30 PORs were allocated to the FPOS group. Basic characteristics, cycle characteristics, and pregnancy outcomes were compared between the two groups.

RESULTS

The length of stimulation was significantly longer in the LPOS group than in the FPOS group. The numbers of retrieved oocytes, metaphase II oocytes, fertilized oocytes, and day-3 embryos were significantly higher in the LPOS group than in the FPOS group. Conversely, we could not find any significant difference for clinical pregnancy rate, ongoing pregnancy rate, abortion rate, and cancellation rate. The multivariate analysis showed that only LPOS (p = 0.007) was significantly associated the possibility to retrieve three or more oocytes, whereas basal follicle-stimulating hormone (FSH) < 8 IU/l (p = 0.103) and antral follicle count (AFC) ≥ 3 (p = 0.143) did not significantly affect this event.

CONCLUSION

LPOS allows improved oocyte retrieval and oocyte quality in PORs with respect to FPOS, despite comparable pregnancy outcomes. LPOS may be considered a feasible option for oocytes accumulation in PORs.

TRIAL REGISTRATION

ClinicalTrials.gov identifier, NCT03238833.

Effects of clomiphene citrate for prevention of premature luteinizing hormone surge in those undergoing intrauterine insemination outcome: A randomized, double-blind, placebo-controlled trial

The objective of the study is to determine the effects of clomiphene citrate (CC) on preventing premature luteinizing hormone (LH) surge in infertile patients with polycystic ovary syndrome (PCOS) undergoing intrauterine insemination (IUI). This was a randomized clinical trial being performed at Shiraz Mother and Child Hospital. We included 162 women with PCOS selected for IUI cycles. Patients were randomly allocated to receive 150 mg/day CC from the 8^th of the cycle though the day of human chorionic gonadotropin (hCG) injection (n = 81) or nothing in the same period (n = 81). Main outcomes included the incidence of premature LH surge, pregnancy rate, abortion and ongoing pregnancy rates, number of maturing follicles, and endometrial thickness. The incidence of premature LH surge was significantly lower in those who received CC (3.0% vs. 14.9%; P = 0.021). The pregnancy rate was 10 (15.1%) and 6 (8.9%) in CC and control groups, respectively (P = 0.342). The ongoing pregnancy rate found to be comparable between two study groups (12.1% vs. 5.9%; P = 0.068). Serum level of estradiol (E₂) level at the time of hCG administration was significantly higher in those who were treated with CC when compared to control (1153.5 ± 326.4 vs. 943.2 ± 215.3; P < 0.001). Patients who received CC also had higher number of mature follicles >18 mm when compared to controls (3.85 ± 1.3 vs. 2.94 ± 1.01; P < 0.001). Administration of CC from the 8^th day of the cycle to the day of hCG injection in combination with Gonal-f in infertile patients with CC-resistant PCOS undergoing IUI cycles is associated with decreased incidence of premature LH surge, higher E₂levels, and higher number of mature ovarian follicles. This protocol is safe and simple and could be considered to be cost-effective.

Clinical experience with an ovarian stimulation protocol for intrauterine insemination adopting a gonadotropin releasing hormone antagonist at low dose

Studies testing the effectiveness of GnRH antagonists in controlled ovarian stimulation (COS) for intrauterine insemination (IUI) have provided controversial results. The present study was undertaken to evaluate, whether the use of a half of the conventional dose of the GnRH antagonist cetrorelix can be effective in increasing the successful rate of IUI cycles. Patients started COS with human menopausal gonadotropin (hMG) on day three of the menstrual cycle. Cetrorelix was started when at least one follicle of ≥14 mm, was detected at the ultrasound scan, according to the flexible multiple daily dose protocol, and continued until the trigger day with recombinant hCG. Patients adopting GnRH antagonist at low dose had a pregnancy rate (21.7%) that was significantly higher (p < 0.05) in comparison to women receiving hMG only (8.7%). These results suggest that adding a reduced dose of GnRH antagonist to the COS for IUI cycles significantly improves the outcome of the procedure.

Evaluation of Role of GnRH Antagonist in Intrauterine Insemination (IUI) Cycles with Mild Ovarian Hyperstimulation (MOH): A Prospective Randomised Study

AIMS AND OBJECTIVE

To evaluate the role of GnRH antagonist in prevention of premature LH surge and increasing pregnancy rates in IUI cycle with mild ovarian hyperstimulation (MOH).

STUDY DESIGN

Prospective parallel, randomised controlled study.

MATERIAL AND METHODS

Couples diagnosed with unexplained, male factor subfertility and with one or both tubes patent were randomised to receive either a GnRH antagonist (study group) or no intervention (control group). All women were treated with clomiphene citrate (D3-D7) followed by HMG. A GnRH antagonist was added when one or more follicles of 16 mm diameter or more were visualised in the study group. When at least one follicle reached a size of ≥18 mm, ovulation was induced by hCG injection. A single IUI was performed 36 h later. The primary outcome was premature LH surge and pregnancy rate. The secondary outcomes were the amount of gonadotropins used, duration of use of GnRH antagonist and incidence and severity of OHSS.

RESULTS

A total of seventy patients attending the infertility clinic in the outpatient department of Obstetrics and Gynecology, of a tertiary care centre, were recruited in the study which was carried out from August 2011 to March 2013. The study group included 34 women and 36 in the control arm. The incidence of premature LH surge was significantly lower in the antagonist group as compared to the control group 2.9 vs. 13.9 %, with a p value of <0.001. The clinical pregnancy rates were similar in both the groups 8.8 vs. 11.1 %, p value being 1.000. The amount of gonadotropins used in GnRH antagonist group was lower than in control group but not statistically significant. Duration of GnRH antagonist was 1.85 ± 0.61 days in the study group.

CONCLUSION

The delayed administration of GnRH antagonists in MOH with IUI cycles when follicle size is ≥16 mm is beneficial in terms of preventing the occurrence of premature LH surge but with no improvement in pregnancy rates.

The Utrogestan and hMG protocol in patients with polycystic ovarian syndrome undergoing controlled ovarian hyperstimulation during IVF/ICSI treatments

Poor oocyte quality is a main concern for decreased reproductive outcomes in women with polycystic ovarian syndrome (PCOS) during controlled ovarian hyperstimulation (COH). A primary way to improve oocyte quality is to optimize the COH protocol. It was demonstrated that the viable embryo rate per oocyte retrieved in the Utrogestan and hMG protocol, a novel regimen based on frozen-thawed embryo transfer (FET), is statistically higher than that in the short protocol. Thus, a retrospective study was conducted to evaluate the endocrine characteristics and clinical outcomes in PCOS patients subjected to the Utrogestan and hMG protocol compared with those subjected to the short protocol.One hundred twenty three PCOS patients enrolled in the study group and were simultaneously administered Utrogestan and human menopausal gonadotropin (hMG) from cycle day 3 until the trigger day. When the dominant follicles matured, gonadotropin-releasing hormone agonist (GnRH-a) 0.1 mg was used as the trigger. A short protocol was applied in the control group including 77 PCOS women. Viable embryos were cryopreserved for later transfer in both groups. The primary outcome was the viable embryo rate per oocyte retrieved. The secondary outcomes included the number of oocytes retrieved, fertilization rate, and clinical pregnancy outcomes from FET cycles.The pituitary luteinizing hormone (LH) level was suppressed in most patients; however, the LH level in 13 women, whose basic LH level was more than 10 IU/L, surpassed 10 IU/L on menstruation cycle day (MC)9-11 and decreased subsequently. No significant between-group differences were observed in the number of oocytes retrieved (13.27 ± 7.46 vs 13.1 ± 7.98), number of viable embryos (5.57 ± 3.27 vs 5 ± 2.79), mature oocyte rate (90.14 ± 11.81% vs 93.02 ± 8.95%), and cleavage rate (97.69 ± 6.22% vs 95.89 ± 9.57%). The fertilization rate (76.11 ± 19.04% vs 69.34 ± 21.81%; P < 0.05), viable embryo rate per oocyte retrieved (39.85% vs 34.68%; P < 0.05), biochemical pregnancy rate (71.72% vs 56.67%; P < 0.05), clinical pregnancy rate (64.65% vs 51.65%; P < 0.05), and implantation rate (46.46% vs 31.35%; P < 0.05) in the study group were significant higher than those in the control group.This study shows that the Utrogestan and hMG protocol was feasible to improve the oocyte quality, possibly providing a new choice for PCOS patients undergoing IVF/ICSI treatments in combination with embryo cryopreservation.

Impact of gonadotropin-releasing hormone antagonist addition on pregnancy rates in gonadotropin-stimulated intrauterine insemination cycles

OBJECTIVES:

The objective of the study is to evaluate the efficacy of gonadotropin-releasing hormone (GnRH) antagonist in improving clinical pregnancy rate in gonadotropin-stimulated intrauterine insemination (IUI) cycles in patients of unexplained infertility.

STUDY DESIGN:

This was a prospective, randomized case-controlled study.

SETTINGS:

The study was conducted in the infertility clinic of a tertiary care center.

MATERIALS AND METHODS:

Four hundred twenty-seven women undergoing IUI following controlled ovarian stimulation with gonadotropins (recombinant follicle-stimulating hormone [r-FSH] 75 IU/day) were randomly divided into two groups. Women in Group I received GnRH antagonist (Cetrorelix 0.25 mg/day) in a multiple dose flexible protocol. Women in Group II received r-FSH alone. Ovulatory trigger was given with human chorionic gonadotropin 5000 IU when dominant follicle was ≥18 mm. IUI was performed within 44–48 h. Both groups received similar luteal phase support. Primary outcome measure was clinical pregnancy rate. The trial was powered to detect an absolute increase in clinical pregnancy rate by 13% from an assumed 20% clinical pregnancy rate in the control group, with an alpha error level of 0.05 and a beta error level of 0.20.

RESULTS:

Clinical pregnancy rate in Groups I and II was 27.6% (n = 56) and 26.5% (n = 54), respectively (P=0.800). Ongoing pregnancy and multiple pregnancy rates were likewise similar between the groups.

CONCLUSIONS:

Addition of GnRH antagonist to gonadotropin-stimulated IUI cycles results in no significant difference in clinical pregnancy rate.

Effect of GnRH antagonists on clinical pregnancy rates in ovulation induction protocols with gonadotropins and intrauterine insemination

INTRODUCTION

Intrauterine insemination (IUI) after controlled ovarian hyperstimulation (COH) was applied to selected infertile patients to determine the effect of gonadotropin-releasing hormone (GnRH) antagonists in IUI cycles, in which recombinant follicle-stimulating hormone (rFSH) had been used for COH.

METHODS

This study was conducted between April 1, 2009 and June 10, 2009, and involved a total of 108 patients. These patients had primary or secondary infertility, which resulted in an indication for IUI, and they each received two cycles of ovarian stimulation treatment with clomiphene citrate. The patients were randomised into two groups--patients in group A received rFSH + GnRH antagonist (n = 45), while those in group B received only rFSH (n = 63).

RESULTS

The mean age of the patients was 31.84 ± 3.73 years and the mean body mass index (BMI) was 24.40 ± 1.88 kg/m(2). The mean age and BMI of the patients in groups A and B were not significantly different. There was no significant difference in the mean total rFSH dose administered (988.33 IU in group A and 871.83 IU in group B). When compared to group B, the mean number of follicles that were > 16 mm on the human chorionic gonadotropin (HCG) trigger day was significantly higher in group A (1.58 and 1.86, respectively; p < 0.05). When the two groups were compared, there were no statistically significant differences in the number of cancelled cycles due to premature luteinisation (none in group A vs. two in group B) and the rate of clinical pregnancy (8.9% in group A vs. 7.9% in group B).

CONCLUSION

No significant improvement in the clinical pregnancy rates was observed when GnRH antagonists were used in COH + IUI cycles, despite the significant increase in the number of follicles that were > 16 mm on HCG trigger day.

Effectiveness of GnRH antagonist in the management of subfertile couples undergoing controlled ovarian stimulation and intrauterine insemination: a meta-analysis

BACKGROUND

Recent studies have indicated the use of gonadotropin-releasing hormone antagonists (GnRH-ant) as an adjuvant treatment to prevent premature luteinization (PL) and improve the clinical outcomes in patients undergoing controlled ovarian stimulation (COS) with intrauterine insemination (IUI). However, the results of these studies are conflicting.

METHODS

We conducted a systematic review and meta-analysis of randomized trials aiming to compare the clinical efficacy of GnRH-ant in COS/IUI cycles. Twelve studies were identified that met inclusion criteria and comprised 2,577 cycles assigned to COS/IUI combined GnRH-ant or COS/IUI alone.

RESULTS

Meta-analysis results suggested that GnRH-ant can significantly increase the clinical pregnancy rate (CPR) (OR = 1.42; 95% CI, 1.13-1.78) and decrease the PL rate (OR = 0.22, 95% CI, 0.16-0.30) in COS/IUI cycles. Subgroup analysis results suggested statistically significant improvement in the CPR in non-PCOS patients (OR = 1.54; 95% CI, 1.03-2.31) but not in the PCOS population (OR = 1.65; 95% CI, 0.93-2.94) and multiple mature follicle cycles (OR = 1.87; 95% CI, 0.27-12.66). There were no difference in the miscarriage and multiple pregnancy rates between the groups.

CONCLUSION

This meta-analysis suggested that GnRH-ant can reduce the incidence of PL and increase the CPR when used in COS/IUI cycles, and it was especially useful for non-PCOS patients. However, evidence to support its use in PCOS patients is still insufficient.

Success in pregnancy through intrauterine insemination at first cycle in 300 infertile couples: an analysis

OBJECTIVE

The aim of this article was to determine digital levels of the association of factors of pregnancy success after the first cycle of intrauterine insemination (IUI) with 300 infertile couples.

METHODS

The IUI procedure was followed at 36 h after triggering the ovulation, if at least one follicle measured >15 mm. Endometrium thickness (ET) and serum luteinizing hormone (LH) levels were measured at day 10 for each patient. The post-wash total motile fraction (TMF) of semen of the partner of each patient was also evaluated. The principal component analysis (PCA) was done with the data to quantify the associations of related factors.

RESULTS

The clinical pregnancy rate of first cycle IUI attempts was 17.3 %, observed in females, aged 20-39 years and men with TMF >5 million spermatozoa. The ovarian stimulation enabled the development of follicles measuring >16 mm, with LH levels <10 mIU/L and ET >5 mm for success. The PCA revealed that with the female-age parameter, three factors, NF, ET, and LH were related in the component 1; similarly, NF, LH, and RFS were related in component 2; age, NF, ET, LH, LFS, and TMF were related in component 3; and NF, ET, LH, RFS, and LFS in component 4 were related, i.e., the best correlation.

CONCLUSIONS

Associated principal determinative factors, LH, female-age, NF and LFS values were highly significant, but the factors, ET, RFS and TMF were statistically insignificant for success through IUI in pregnancy.

Effect of gonadotropin-releasing hormone antagonists on intrauterine insemination cycles in women with polycystic ovary syndrome: a meta-analysis

Polycystic ovary syndrome (PCOS) patients undergoing controlled ovarian stimulation and intrauterine insemination (COS/IUI) often face the risk of premature luteinization, which may result in lower pregnancy rate and higher miscarriage rate. This review was performed to identify if adjuvant treatment with GnRH antagonist (GnRH-ant) could effectively improve the clinical outcome of patients with PCOS undergoing COS/IUI. A literature search was conducted on the PubMed, EMBASE and Cochrane library databases. Two randomized controlled trials were included in this review, enrolling a total of 333 cycles. The patients who received GnRH-ant treatment had lower progesterone levels on the hCG day and a reduced premature luteinization rate. However, the rates of live birth, clinical pregnancy and miscarriage did not significantly differ between the GnRH-ant supplementation group and control group. In conclusion, although the existing randomized controlled trials indicate that GnRH-ant can effectively decrease the premature luteinizaton rate, evidence to support its use to improve clinical pregnancy outcomes in PCOS patients undergoing COS/IUI treatment is insufficient.

Cessation of gonadotropin-releasing hormone antagonist on triggering day in flexible multiple-dose protocol: A randomized controlled study

Objective

To investigate outcomes of stimulated IVF cycles in which GnRH antagonist was omitted on the ovulation triggering day.

Methods

A total of 86 women who underwent controlled ovarian hyperstimulation with recombinant FSH and GnRH antagonist flexible multiple-dose protocols were recruited and prospectively randomized into the conventional group (group A) or cessation group (group B). The GnRH antagonist, 0.25 mg/day of cetrorelix, was started when the leading follicle reached 14 mm in diameter and was continuously administered until the hCG triggering day (group A, 43 cycles) or until the day before hCG administration (group B, 43 cycles). The maturity of oocytes, fertilization rate, embryo quality, and implantation and clinical pregnancy rates were evaluated.

Results

The duration of ovarian stimulation, total dose of gonadotropins, serum estradiol levels on hCG administration day, and number of oocytes retrieved were not significantly different between the two groups. The total dose of GnRH antagonist was significantly lower in group B than group A (2.5±0.9 vs. 3.2±0.8 ampoules, p<0.05). There was no premature luteinization in any of the subjects. The proportion of mature oocytes and fertilization rate were not significantly different in group B than group A (70.7% vs. 66.7%; 71.1% vs. 66.4%, respectively). There were no significant differences in the implantation or clinical pregnancy rates.

Conclusion

Our prospective randomized study suggested that cessation of GnRH antagonist on the hCG administration day during a flexible multiple-dose protocol could reduce the total dose of GnRH antagonist without compromising its effects on pregnancy rates.

The effectiveness of earlier oocyte retrieval in the case of a premature luteinizing hormone surge on hCG day in in vitro fertilization-embryo transfer cycles

Objective

To evaluate the efficacy of earlier oocyte retrieval in IVF patients with a premature LH surge on hCG day.

Methods

One hundred forty IVF patients (164 cycles) with premature LH surge on hCG day were included, retrospectively. We divided them into 2 study groups: LH surge with timed ovum pick-up (OPU) 36 hours after hCG injection (group B, 129 premature cycles), and LH surge with earlier OPU within 36 hours after hCG injection (group C, 35 cycles). Control groups were tubal factor infertility without premature LH surge (group A, 143 cycles).

Results

The mean age (year) was statistically higher in group C than in groups A or B (38.2±5.4 vs. 36.2±4.2 vs. 36.8±4.9, respectively; p=0.012). The serum LH levels (mIU/mL) on hCG day were significantly higher in group B and C than in group A (22.7±14.9 vs. 30.3±15.9 vs. 3.2±2.9, respectively; p>0.001). Among groups A, B, and C, 4.9%, 31.7%, and 51.4% of the cycles, respectively, had no oocytes, and the overall rates of cycle cancellation (OPU cancellation, no oocyte, or no embryos transferrable) were 15.4%, 65.9%, and 74.3%, respectively. The fertilization rate (%) was significantly higher in group B than in group C (73.2±38.9 vs. 47.8±42.9, p=0.024). The clinical pregnancy rate was significantly higher in group C than in groups A and B (44.4% vs. 27.3% vs. 9.1%, respectively, p=0.021). However, the miscarriage rate was also higher in group C than in group B (22% vs. 0%, respectively, p=0.026).

Conclusion

Earlier OPU may not be effective in reducing the risk of cycle cancellation in patients with premature LH surge on hCG day. A larger scale study will be required to reveal the effectiveness of earlier ovum retrieval with premature LH surge.

Effectiveness of GnRH antagonist in intrauterine insemination cycles

OBJECTIVE

To evaluate the effectiveness of GnRH antagonists in women undergoing controlled ovarian stimulation and intrauterine insemination cycles (COS/IUI).

STUDY DESIGN

Randomized controlled trial. Recruited women were randomized into two groups: GnRH antagonist and control group. The primary outcomes were incidence of premature LH surge and clinical pregnancy rates.

RESULTS

One hundred and forty-one consecutive women were included in the study, with 70 in the antagonist group and 71 in the control arm. The baseline clinical characteristics were similar in both groups. The incidence of premature LH surge and premature luteinization was lower in the antagonist group as compared to the control group (5% vs. 10.3%, P=0.45 and 5% vs. 13.8, P=0.31) but not statistically significant. The clinical pregnancy rates were lower in the antagonist group (2.8% vs. 10%, P=0.12), which was also not statistically significant.

CONCLUSION

The addition of GnRH antagonist during controlled ovarian stimulation and intrauterine insemination cycles does not lead to improvement in clinical pregnancy rates.

Prognostic value of serum progesterone and LH values on the day of hCG administration in IUI GnRH antagonist cycles

OBJECTIVE

to evaluate the effect of LH surge and progesterone rise in IUI cycles under gonadotropin stimulation with GnRH antagonist coadministration on pregnancy rates (PR).

STUDY DESIGN

The population under study consisted of 152 women prospectively studied and subjected to IUI.

RESULTS

The higher the progesterone cutoff value, the lower the PR were 26.5% and 10.9% when the cutoff was 1 ng/mL, 26.0% and 8.6% when the cutoff was 1.2 ng/mL, 25.6% and 7.1% when the cutoff was 1.4 ng/mL and 25.3% and 0% when the cutoff was 1.6 ng/mL.

CONCLUSION

In IUI cycles under GnRH antagonist coadministration, serum progesterone levels over 1.0 ng/mL are associated with lower PR, the higher the progesterone levels, the lower the PR.

Efficacy of the motile sperm organelle morphology examination (MSOME) in predicting pregnancy after intrauterine insemination

BACKGROUND

Although the motile sperm organelle morphology examination (MSOME) was developed merely as a selection criterion, its application as a method for classifying sperm morphology may represent an improvement in the evaluation of semen quality. The aim of this study was to determine the prognostic value of normal sperm morphology using MSOME with regard to clinical pregnancy (CP) after intrauterine insemination (IUI).

METHODS

A total of 156 IUI cycles that were performed in 111 couples were prospectively analysed. Each subject received 75 IU of recombinant FSH every second day from the third day of the cycle. Beginning on the 10th day of the cycle, follicular development was monitored by vaginal ultrasound. When one or two follicles measuring at least 17 mm were observed, recombinant hCG was administered, and IUI was performed 12-14 h and 36-40 h after hCG treatment. Prior to the IUI procedure, sperm samples were analysed by MSOME at 8400× magnification using an inverted microscope that was equipped with DIC/Nomarski differential interference contrast optics. A minimum of 200 motile spermatozoa per semen sample were evaluated, and the percentage of normal spermatozoa in each sample was determined.

RESULTS

Pregnancy occurred in 34 IUI cycles (CP rate per cycle: 21.8%, per patient: 30.6%). Based on the MSOME criteria, a significantly higher percentage of normal spermatozoa was found in the group of men in which the IUI cycles resulted in pregnancy (2.6+/-3.1%) compared to the group that did not achieve pregnancy (1.2+/-1.7%; P = 0.019). Logistic regression showed that the percentage of normal cells in the MSOME was a determining factor for the likelihood of clinical pregnancy (OR: 1.28; 95% CI: 1.08 to 1.51; P = 0.003). The ROC curve revealed an area under the curve of 0.63 and an optimum cut-off point of 2% of normal sperm morphology. At this cut-off threshold, using the percentage of normal sperm morphology by MSOME to predict pregnancy was 50% sensitive with a 40% positive predictive value and 79% specificity with an 85% negative predictive value. The efficacy of using the percentage of normal sperm morphology by MSOME in predicting pregnancy was 65%.

CONCLUSIONS

The present findings support the use of high-magnification microscopy both for selecting spermatozoa and as a routine method for analysing semen before performing IUI.

Predictive factors for pregnancy after intrauterine insemination: A prospective study of factors affecting outcome

OBJECTIVE:

To determine the predictive factors for pregnancy after controlled ovarian hyperstimulation (COH)/intrauterine insemination (IUI).

DESIGN:

Prospective observational study.

SETTING:

University-level tertiary care center.

PATIENTS AND METHODS:

366 patients undergoing 480 stimulated IUI cycles between November 2007 and December 2008.

INTERVENTIONS:

Ovarian stimulation with gonadotrophins was initiated and a single IUI was performed 36 h after triggering ovulation.

MAIN OUTCOME MEASURES:

The primary outcome measures were clinical pregnancy and live birth rates. Predictive factors evaluated were female age, duration of infertility, indication for IUI, number of preovulatory follicles, luteinizing hormone level on day of trigger and postwash total motile fraction (TMF).

RESULTS:

The overall clinical pregnancy rate and live birth rate were 8.75% and 5.83%, respectively. Among the predictive factors evaluated, the duration of infertility (5.36 vs. 6.71 years, P = 0.032) and the TMF (between 10 and 20 million, P = 0.002) significantly influenced the clinical pregnancy rate.

CONCLUSION:

Our results indicate that COH/IUI is not an effective option in couples with infertility due to a male factor. Prolonged duration of infertility is also associated with decreased success, and should be considered when planning treatment.

Gonadotrophin ovulation induction and enhancement outcomes: analysis of more than 1400 cycles

Ovulation induction (OI) or ovulation enhancement (OE) with gonadotrophins can be a reasonable treatment option for patients with a variety of infertility diagnoses. It must be used with extensive monitoring and management given the risk of multiple pregnancy,especially high-order multiples. This retrospective study evaluated per cycle outcomes of a large cohort of 1452 gonadotrophin OI/OE cycles at an academic infertility centre, and the efficacy of specific guidelines in limiting multiple pregnancy. The lowest possible gonadotrophin doses were used and cycle cancellation was recommended if more than three dominant follicles were present, and/or ifserum oestradiol was above 1500 pg/ml. Overall, pregnancy rate (PR) was 12% and live birth rate was 7.7%, with an increasing trend in younger patients (P = 0.0002 and <0.0001, respectively). Multiple clinical PR was 2.6% with 1.9% twins and 0.7% triplets and above.The birthweight of a singleton from a vanishing twin pregnancy (n = 8)was significantly lower than other singletons (2882 g versus 3250 g,P = 0.013). Reducing multiple pregnancies from OI/OE cycles remains an important and challenging goal. In this large cohort, high-order multiple clinical PR was limited to 0.7% per cycle by using specific management strategies while maintaining a reasonable PR.

Comparison of the effect of two different doses of recombinant gonadotropin for ovarian stimulation on the outcome of intrauterine insemination

OBJECTIVE

The aim of this study was to identify an optimal stimulation protocol for intrauterine insemination (IUI) to obtain an acceptable pregnancy rate and low frequency of multiple pregnancies.

MATERIALS AND METHODS

In total, 340 patients, who received intrauterine insemination because of ovulation dysfunction, were enrolled in this study. Group I consisted of 203 patients who received recombinant FSH (r-FSH) 150U every other day as an ovulation induction agent. Group II consisted of 137 patients who received r-FSH 100U every other day as an ovulation induction agent. All patients in both groups also received clomiphene citrate 100 mg/day for consecutive five days from the fifth day of the cycle. Only patients with at least two follicles >18 mm on the human chorionic gonadotropin injection days were included in this study.

RESULTS

The clinical pregnancy rate was 14.8% (30/203) in Group I compared with 20.4% (28/137) in Group II, p > 0.05. The incidence of multiple pregnancy was 41.7% (10/24) in Group I compared with 12.5% (3/24) in Group II, p < 0.05.

CONCLUSIONS

The concurrent use of low-dose r-FSH and clomiphene citrate would seem not only to be cost-effective but also highly satisfactory in that it prevents high-order multiple pregnancies.

Role of gonadotropin-releasing hormone antagonist in the management of subfertile couples with intrauterine insemination and controlled ovarian stimulation

OBJECTIVE

To assess whether the clinical pregnancy rate of patients treated with recombinant FSH and IUI can be improved by the addition of a GnRH antagonist.

DESIGN

Prospective, controlled study.

SETTING

Reproductive medicine clinic.

PATIENT(S)

Ninety-three patients with primary or secondary infertility.

INTERVENTION(S)

Patients were allocated to controlled ovarian stimulation with recombinant FSH (50-150 IU/d) only (control group, n=45) or to recombinant FSH (50-150 IU/d) plus ganirelix (0.25 mg/d, starting when the leading follicle was ≥16 mm; n=48). A single insemination was performed 36 hours after hCG was given (10,000 IU, IM) in both groups. Both groups were allowed at least three cycles.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rate, premature luteinization rate, and follicular development.

RESULT(S)

Clinical pregnancy rate (22% vs. 11%), cumulative pregnancy rate (52% vs. 31%), and number of mature follicles (2.1±1.08 vs. 1.4±0.95) were statistically significantly higher in the ganirelix group compared with the control group. The premature luteinization rate was significantly lower in the ganirelix group (1.7% vs. 17.5%).

CONCLUSION(S)

The use of a GnRH antagonist in conjunction with controlled ovarian stimulation and IUI significantly increases pregnancy rates and reduces the incidence of premature luteinization.

Cetrorelix lowers premature luteinization rate in gonadotropin ovulation induction-intrauterine insemination cycles: a randomized-controlled clinical trial

Attempting to compare the rates of premature luteinization (PL), clinical pregnancy, and cycle cancellation in ovulation induction-intrauterine insemination (OI-IUI) cycles with and without the GnRH antagonist, cetrorelix, a randomized-controlled trial was undertaken in which patients were randomized to one of two OI-IUI protocols. Those in the cetrorelix arm showed a significantly reduced rate of PL and no change in clinical pregnancy or cycle cancellation rate, leading to the conclusion that GnRH antagonists can decrease the rate of PL, but appear to have no effect on pregnancy or cycle cancellation in gonadotropin OI-IUI cycles.

Gonadotropin-releasing hormone antagonist use in controlled ovarian stimulation and intrauterine insemination cycles in women with polycystic ovary syndrome

OBJECTIVE

To observe the effects of ganirelix on controlled ovarian stimulation and intrauterine insemination (COS/IUI) cycles in women with polycystic ovary syndrome (PCOS).

DESIGN

Prospective, randomized, controlled clinical study.

SETTING

An academic clinical research center.

PATIENT(S)

Women with PCOS and anovulatory infertility undergoing COS/IUI.

INTERVENTION(S)

Recombinant FSH therapy was started on day 3. In women assigned to the control group (n = 47), treatment was continued up to the day of hCG administration. In patients assigned to receive GnRH antagonist (n = 42), ganirelix was added when the leading follicle was > or =14 mm.

MAIN OUTCOME MEASURE(S)

Pregnancy rates, serum E(2), P, and LH levels, and follicle numbers at hCG day, prevalence of premature luteinization, and cost of stimulation.

RESULT(S)

Serum E(2), P, and LH levels were significantly lower in the ganirelix group. Although premature luteinization and cycle cancellation was encountered less in the ganirelix group, the pregnancy rates per cycle were similar (15.4% vs. 10.7%). Patients would pay 6,153 dollars more for each pregnancy when using ganirelix.

CONCLUSION(S)

Gonadotropin-releasing hormone antagonist resulted in more monofollicular development, less premature luteinization, and less cycle cancellation in IUI cycles of patients with PCOS; however, the cost of stimulation increased without an improvement in pregnancy rates.

Offering excess oocyte aspiration and vitrification to patients undergoing stimulated artificial insemination cycles can reduce the multiple pregnancy risk and accumulate oocytes for later use

BACKGROUND

The prevention of multiple pregnancies remains a major challenge in patients treated with ovarian stimulation prior to intrauterine insemination (IUI). The pilot study presented here investigates whether multiple pregnancies can be minimized by a microscopically confirmed aspiration of oocytes from supernumerary follicles immediately before intrauterine insemination and evaluates the benefit of concomitant excess oocyte cryopreservation for future use.

METHODS

Thirty-four aspirations of supernumerary follicles were performed immediately prior to IUI in 31 patients undergoing ovarian stimulation. sIUI was only performed if cumulus-oocyte complexes were microscopically observed in the aspirated follicular fluid. All collected mature excess oocytes were cryopreserved using the vitrification technique.

RESULTS

Only four sIUI procedures had to be cancelled due to failed oocyte retrieval or premature ovulation. IUI treatment resulted in a clinical pregnancy rate of 23.5% per cycle. All were singleton pregnancies. A total of 111 oocytes were cryopreserved. Patients with polycystic ovary syndrome (PCOS) had an average of 6.07 oocytes vitrified, whereas patients without PCOS had 1.3 oocytes vitrified per cycle.

CONCLUSION

Microscopically confirmed collection of excess oocytes prior to stimulated IUI reduced cancellation rates, further reduced the risk for multiple pregnancy and may lead to future additional pregnancies because, based on current information, approximately 5% of the vitrified oocytes could potentially establish a pregnancy.

GnRH antagonist ganirelix prevents premature luteinization in IUI cycles: rationale for its use

This study evaluated the efficacy of a gonadotrophin-releasing hormone antagonist (GnRHa) to prevent premature luteinization (PL) and examined its impact on intrauterine insemination (IUI) cycle outcome. A total of 662 patients who were undergoing IUI were evaluated. Ovarian stimulation was started on day 3 with recombinant (r)FSH, followed by the GnRHa and recombinant human chorionic gonadotrophin (rHCG). The overall incidence of PL was 11.5%. In patients with and without PL, the pregnancy rates (PR) were 22.4 (17/76) and 17.7% (104/586) respectively. Patients with PL were divided into two groups: (i) those with increased serum progesterone [PR was 10.7% (3/28) in this group]; and (ii) patients with elevated serum LH but normal progesterone concentrations [PR was 29.2% (14/48) in this group]. Patients in the first group who did not become pregnant (n = 22) were administered GnRHa in a second IUI cycle, and the PR was 18.1%; however, some patients (n = 6; 27.3%) in this group still had high serum progesterone concentrations. In the second group, patients (n = 26) with elevated serum LH in the previous cycle were administered GnRHa in another IUI and the PR was 23.1%. Use of a GnRHa in patients with PL who have had a previous unsuccessful IUI may be an alternative in future attempts.

Cessation of gonadotropin-releasing hormone antagonist on triggering day: an alternative method for flexible multiple-dose protocol

This study was performed to analyze retrospectively outcomes of stimulated in vitro fertilization (IVF) cycles where the gonadotropin-releasing hormone (GnRH) antagonist was omitted on ovulation triggering day. A total of 92 consecutive IVF cycles were included in 65 women who are undergoing ovarian stimulation with recombinant FSH. A GnRH antagonist, cetrorelix 0.25 mg/day, was started when leading follicle reached 14 mm in diameter until the day of hCG administration (Group A, 66 cycles) or until the day before hCG administration (Group B, 26 cycles). The duration of ovarian stimulation, total dose of gonadotropins, serum estradiol levels on hCG administration day, and the number of oocytes retrieved were not significantly different between the two groups. The total dose of GnRH antagonist was significantly lower in Group B compared to Group A (2.7+/-0.8 vs. 3.2+/-0.9 ampoules). There was no premature luteinization in the subjects. The proportion of mature oocytes (71.4% vs. 61.7%) and fertilization rate of mature (86.3+/-19.7% vs. 71.8+/-31.7%) was significantly higher in Group B. There were no significant differences in embryo quality and clinical pregnancy rates. Our results suggest that cessation of the GnRH antagonist on the day of hCG administration during a flexible multiple-dose protocol could reduce the total dose of GnRH antagonist without compromising IVF results.

Does premature luteinization or early surge of LH impair cycle outcome? Report of two successful outcomes

PURPOSE

To report two successful antagonist IVF cycles; one ending up with pregnancy despite premature luteinization (case 1, aged 35 years), and the other with the retrieval of high quality oocytes despite premature ovulation (case 2, aged 39 years).

METHODS

Serum LH was 36 and 47 IU/L on cycle day 7 before antagonist administration, which was then brought to 6.94 and 3.92 IU/L by antagonist administration, and kept below these levels throughout the remaining stimulation in case 1 and 2 respectively. Serum progesterone was 1.42 and 5.5 ng/mL on the day of hCG respectively. Ten metaphase II (MII) oocytes were harvested wherein 3 grade A embryos were transferred in case 1, and seven good quality MII oocytes were retrieved wherein six embryos were cryopreserved in case 2.

CONCLUSIONS

More precise cut thresholds for both LH and progesterone are necessary for accurate prediction of the cycle outcomes.

Predictors of ovarian response in intrauterine insemination patients and development of a dosage nomogram

The objective of this prospective study was to identify predictors of ovarian response in ovulatory patients treated with low-dose recombinant FSH (rFSH), gonadotrophin-releasing hormone antagonist and intrauterine insemination (IUI), and to develop an rFSH dosage nomogram based on the findings. Patients (n = 159) were stimulated with a starting dose of 75 IU rFSH/day. Ten parameters were investigated as possible predictors of the number of mature follicles >or=15 mm: age, spontaneous cycle length, body weight, body mass index, smoking status, total ovarian volume, total number of antral follicles, total Doppler score of the ovarian stromal blood flow, baseline FSH and oestradiol. Simple and multiple linear regressions were used for the statistical analysis. Appropriate ovarian response was defined as two to three mature follicles. Body weight (P = 0.001) and the number of antral follicles (P = 0.004) were the strongest independent predictive factors of the number of mature follicles. In conclusion, body weight and antral follicle count may be used to achieve appropriate ovarian response for IUI in ovulatory patients. Based on this, a simple rFSH dosage nomogram was developed for individual ovarian stimulation prior to IUI.

Bias in frequently reported analyses of subfertility trials

Randomized controlled trials in subfertility are often designed so that participants in each trial arm are offered the randomized treatment for up to k cycles, until success occurs. In clinical journals, success probabilities are often reported 'per cycle' and inferential procedures carried out as if all cycles were independent. However, this assumption does not hold. In this paper we consider the implications of such an assumption when we have a heterogeneous (Beta) patient population. We conducted a simulation study to assess the bias of estimates of the risk difference, risk ratio and odds ratio calculated using the total number of randomized women or the total number of treatment cycles as the unit of analysis, as well as the coverage of their confidence intervals (CIs). We found that the commonly reported 'per cycle' analyses are more biased and have poorer coverage of the CIs than the analyses based on the total number of women, in heterogeneous populations. Such information will help researchers who wish to interpret publications when the number of randomized participants is not extractable.

Oral contraceptive pretreatment and half dose of ganirelix does not excessively suppress LH and may be an excellent choice for scheduling IUI cycles

PURPOSE

To assess the effects of using a reduced dose of ganirelix with oral contraceptive pretreatment in a pilot study of COH using pure FSH for intrauterine insemination (IUI) METHODS: Patients received oral contraceptive (OC; 30 microg ethinyl estradiol/150 microg desogestrel) for 14-21 days and rFSH (50-225 IU/day SC) was started on day 4 after OC discontinuation. Ganirelix acetate (125 microg/day) was started with a lead follicle diameter of 14 mm.

RESULTS

Of the 25 subjects who started oral contraceptives, one was cancelled due to an excessive response, and one subject was not included in the analysis because she did not receive ganirelix until the lead follicle was 18 mm. Median (range) starting FSH dose was 100 (50-225), cumulative rFSH dose was 1000 (675-2175) IU over 10 (9-17) days. Duration of ganirelix acetate treatment was 4.0 (2-5) days. Seven subjects (30.4%) delivered ten babies (three pregnancies were twins). There were no biochemical pregnancies or miscarriages. Of the 16 subjects with measurement of LH on the day of HCG administration, only one was under 0.5 mIU/ml (0.4), and only one was over 10 mIU/ml (17.7), and that subject delivered twins.

CONCLUSION

OC pretreatment afforded flexibility in scheduling while a reduced dose of ganirelix avoided excessive suppression of LH. The excellent results in this pilot study for IUI suggest this regimen could be further evaluated for scheduling IUI and IVF cycles.

[The use of GnRH antagonists in ovarian stimulation for intrauterine inseminations: is there any interest?]

The use of the GnRH antagonists during ovarian stimulation for intrauterine insemination is relatively recent. The primary aim was to improve the timing of the inseminations on working days. However, according to published data, the consequences on pregnancy rate remain uncertain. Moreover, the impact of this strategy on stimulation's parameters, specifically on the size of the follicle cohort, should be better assessed.

Effectiveness of cetrorelix for the prevention of premature luteinizing hormone surge during controlled ovarian stimulation using letrozole and gonadotropins: a randomized trial

OBJECTIVE

To evaluate the effectiveness of a GnRH antagonist in preventing premature LH surge under a letrozole and gonadotropin protocol.

DESIGN

Prospective, randomized clinical trial.

SETTING

A teaching hospital and tertiary medical center.

PATIENT(S)

Sixty-one patients were randomly assigned into two letrozole and gonadotropin-treated groups. These were distinguished by the absence (group I) or presence (group II) of supplementation with 0.25 mg of cetrorelix.

INTERVENTION(S)

Controlled ovarian stimulation with letrozole and gonadotropins, cetrorelix and intrauterine insemination.

MAIN OUTCOME MEASURE(S)

Rate of premature LH surge.

RESULT(S)

Compared with group I, the rate of premature LH surge was statistically significantly lower for group II (43.4% [13/30] vs. 19.4% [6/31]), but the amount of gonadotropins used was statistically significantly higher (817.5 +/- 28.5 vs. 907.5 +/- 27.3 IU). Patients with premature LH surge had a statistically significantly lower pregnancy rate (21.4% [9/42] vs. 0 [0/18]) relative to their unaffected counterparts.

CONCLUSION(S)

A flexible protocol of 0.25 mg of cetrorelix for IUI cycles appears to suppress the rate of premature LH surge during ovarian stimulation with letrozole and gonadotropins. However, the incidence of premature LH surge remains too high, and modification will be necessary before the application of cetrorelix to IVF treatment.

Effects and clinical significance of GnRH antagonist administration for IUI timing in FSH superovulated cycles: a meta-analysis

OBJECTIVES

To compare the administration of GnRH antagonist in gonadotropin intrauterine insemination (IUI) cycles with cycles where no intervention took place.

DESIGN

Meta-analysis of published prospective randomized trials.

PATIENTS(S)

Five hundred twenty-one patients who were administered a GnRH antagonist and 548 conservatively treated patients who served as control subjects were included in the meta-analysis.

INTERVENTION(S)

STUDY SELECTION

Prospective trials were retrieved from Medline and Cochrane Library (last update October 2006). Random effect analysis was used in this meta-analysis. Two independent reviewers performed data extraction.

MAIN OUTCOME MEASURE(S)

Clinical pregnancy rates.

RESULT(S)

Six comparisons were retrieved including 1,069 patients. Higher pregnancy rates were found in the randomized controlled trials (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.05-2.33) when a GnRH antagonist was added to a gonadotropin superovulated IUI protocol. Early published studies with smaller sample sizes showed stronger associations (OR 2.31, 95% CI 1.15-4.63) than later studies (OR 1.32, 95% CI 0.79-2.23).

CONCLUSION(S)

From the randomized controlled trials of this meta-analysis, it is clear that allowing for follicle growth and avoiding premature LH rise, increased pregnancy rates are observed with GnRH antagonist administration. A parallel trend for multiple pregnancy rates in the GnRH antagonist group was observed, although this did not reach statistical significance. The flexible regimen was widely used. This meta-analysis of early data might enhance further research in this direction.